Healthcare Provider Details

I. General information

NPI: 1790171775
Provider Name (Legal Business Name): JENNIFER LYNN GRESHAM RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2015
Last Update Date: 04/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 N HIGLEY RD
GILBERT AZ
85234-1604
US

IV. Provider business mailing address

2964 E CLARENDON AVE
PHOENIX AZ
85016-7063
US

V. Phone/Fax

Practice location:
  • Phone: 480-543-2485
  • Fax:
Mailing address:
  • Phone: 520-604-0017
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number156185
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: